Independence would like to remind you that, per your Independence Professional Provider Agreement and/or Hospital, Ancillary Facility, or Ancillary Provider Agreement (Agreement), you are required to notify Independence whenever key provider demographic information changes. Submitting changes in a timely manner helps to ensure prompt payment of claims, delivery of critical communications, seamless recredentialing, and accurate listings in our provider directories.

Professional providers*

Independence requires at least 30 days advanced written notice to process most updates as long as the information submitted is accurate. For a complete outline of the advanced written notice time frames that Independence requires to process most updates, refer to the Administrative Procedures section of the Provider Manual for Participating Professional Providers (Provider Manual). Most of the changes to basic practice information can be quickly submitted using the Provider Change Form .

Note: The Provider Change Form cannot be used if you are closing your practice or terminating from the network. Refer to ?Resignation/ termination from the Independence network? in the Administrative Procedures section of the Provider Manual for more information regarding these policies and procedures.

Facility and ancillary providers

As outlined in the Administrative Procedures section of the Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers, Independence requires at least 30 days advanced written notice to process changes to your information as long as the information submitted is accurate.

Per your Agreement, all changes must be submitted in writing to our contracting and legal departments at the following addresses:

• Independence Blue Cross
• Attn: Vice President, Contracting and Reimbursement
• 1901 Market Street, 27th Floor
• Philadelphia, PA 19103

• Independence Blue Cross
• Attn: Deputy General Counsel, Managed Care
• 1901 Market Street, 43rd Floor
• Philadelphia, PA 19103

Authorizing signature and W-9 Forms

Updates resulting in a change on your W-9 Form (e.g., changes to a provider?s name, tax ID number, billing vendor or ?pay to? address, or ownership) require the following signatures:

• For professional providers:
• – Group practices: A signature from a legally authorized representative (e.g., physician or other person who signed the
  professional group provider agreement or one who is legally authorized to bind the group practice) of the practice is required.
• – Solo practitioners: A signature from the individual practitioner is required.
• For facility and ancillary providers: Written notification on company letterhead is required.

An updated copy of your W-9 Form reflecting these changes must also be included to ensure that we provide you with a correct 1099 Form for your tax purposes. If you do not submit a copy of your new W-9 Form, your change will not be processed.

Independence will not be responsible for changes not processed due to lack of proper notice. Failure to provide proper advanced written notice to Independence may delay or otherwise affect provider payment. If you have any questions about updating your provider information, please contact your Network Coordinator.

*To ensure appropriate setup in Independence systems, the time frames outlined above also apply to behavioral health providers contracted with Magellan Healthcare, Inc., an independent company. Behavioral health providers must submit any changes to their practice information to Magellan via their online Provider Data Change form by selecting the ?Display/Edit Practice Info? link.

Magellan Healthcare, Inc. manages mental health and substance abuse benefits for most Independence members.